Derek Burnett
Derek Burnett is a Contributing Writer at Bottom Line Personal, where he writes frequently on health and wellness. He is also a contributing editor with Reader’s Digest magazine.
Different men whose prostates have become enlarged (a condition called benign prostatic hyperplasia, or BPH), can have wildly varying experiences. Some are fortunate enough to have no symptoms at all, while others see their quality of life deteriorate alarmingly. The prostate, a normally walnut-sized sex gland, surrounds the urethra, the tube that drains the bladder. When the prostate increases dramatically in size (a normal part of aging) its outsized tissues can choke off the urethra, causing a host of urinary symptoms including difficulty starting to pee, increased urgency, frequent nighttime urination, and incontinence. The best treatment for an enlarged prostate is heavily dependent of the symptoms a man is experiencing, and the potential for side effects it might have..
Often when men ask themselves, “Okay, so what is the best treatment for an enlarged prostate?” they are hoping for an easy fix. As with so many medical questions, there isn’t a single drug or procedure that’s going to be best for all men. Choosing a treatment for enlarged prostate must be done carefully, taking into account your severity of symptoms, your preferences regarding surgery versus medication, your concerns about side effects and complications, and your patience and tolerance for uncertainty. Generally speaking, enlarged prostate treatment falls into three broad categories:
Also known as “active surveillance,” this strategy consists of monitoring the condition until symptom severity makes it clear that some form of active treatment is necessary. Obviously, someone whose symptoms are already impossible to live with will not choose this option. But people without symptoms or whose symptoms are only a mild inconvenience may opt to hold off on treatments for a while, especially if they don’t like taking medications or would rather not undergo a procedure.
Normally, a person in watchful waiting mode will visit a urologist twice a year to undergo careful examination and to report any symptoms such as difficulty urinating or increased frequency of urination. If the person experiences any complications of the condition like bloody urine, inability to urinate, or infection, he should report these events immediately to his physician so they can be addressed and, if more active treatment measures are deemed necessary, so that he can move on to them promptly.
For men already experiencing annoying symptoms, doctors will usually try medication before surgery. There are two main classes of drugs used to treat BPH.
Alpha blockers. These medications do not shrink the prostate, but they help to relax the muscles in the bladder, especially where it connects to the prostate, an area that can be a common choke point, to make it easier to urinate. These drugs include doxazosin mesylate (Cardura), terazosin hydrochloride (Hytrin), and tamsulosin HCI (Flomax). Some men taking alpha blockers experience unpleasant side effects such as low blood pressure, dizziness, and problems with ejaculation.
5-alpha reductase inhibitors. Unlike alpha blockers, the 5-alpha reductase inhibitors finasteride (Proscar) and dutasteride (Avodart) bring down the size of the prostate by reducing levels of the hormone dihydrotestosterone (DHT), which is known to encourage prostate growth. Its side effects can include loss of interest in sex, erectile dysfunction, and trouble with ejaculating.
If BPH drugs aren’t working to control symptoms, or if a person is uncomfortable with the side-effect profiles of the medication options, he may decide, in consultation with his doctor, to pursue a surgical treatment. Just as with deciding on a general treatment plan, however, there is no single-best procedure for all men. Today, there are more procedures to choose from than ever. They include:
Transurethral resection of the prostate (TURP). This is the most commonly performed procedure for BPH. While the person is under anesthesia, surgeons insert a tool called a resectoscope into the end of the penis and through the urethra, to access the prostate and bladder. They then cut away parts of the prostate to take pressure off the urethra. A TURP takes 60-90 minutes and may require a hospital stay of a day or two. Rarely, men experience sexual dysfunction following a TURP.
Transurethral incision of the prostate (TUIP).As with a TURP, a TUIP involves reaching the prostate with a resectoscope via the urethra. But rather than cutting off parts of the prostate, the surgeon makes incisions in its tissue to widen the passage through which urine travels. TUIP is considered less invasive than TURP and can be done on an outpatient basis, with fewer side effects and complications. However, it is also somewhat less effective, and may require additional treatments.
Holmium laser enucleation of the prostate (HoLEP). This procedure, which takes about three hours but is considered minimally invasive, removes a considerably larger portion of the prostate than a TURP. Like a TURP or a TUIP, it uses a resectoscope inserted into the urethra, but uses laser pulses to clear away the prostate’s interior tissues which are causing bladder and urethra blockages. It is considered to be as effective as full removal of the prostate.
GreenLight laser treatment.Very similar to HoLEP, GreenLight uses a different type of laser. It is less effective on prostates with larger volume, and in some studies has proved inferior to HoLEP in terms of safety and durability. However, due to the fact that it cauterizes blood vessels, there is reportedly significantly less blood loss than HoLEP and results in a shorter hospital stay.
Aquablation. Approved by the FDA in 2017, aquablation is a minimally invasive, robotic procedure that takes place in two steps. First, surgeons use an imaging machine to create a precise map of the man’s anatomy so that the intervention will be highly targeted only to the tissues causing the obstruction. Second, a high-pressure jet of water, guided by the anatomical map, is used to destroy the excess prostate tissue. Aquablation has been found to be more effective, with fewer side effects, than TURP.
Prostatic artery embolization (PAE).This procedure is performed by an interventional radiologist, who inserts a small catheter into the man’s wrist or groin, which is then run to the blood vessels supplying the prostate. Once there, the radiologist inserts tiny particles into the arteries, deliberately creating a blockage that cuts off blood flow to the prostate so that it will shrink and no longer block the urethra. Some men experience fever, pain, vomiting, and painful urination over the following days, a condition known as “post-PAE syndrome.”
UroLift.Rather than destroying or removing excess prostate tissue, a UroLift simply moves it out of the way. Accessing the prostate via the urethra, the surgeon inserts tiny implants into the prostate tissue to pull it back from obstructing the urethra. One of the benefits of UroLift is that is has no effect on a man’s sexual function or libido.
Rezūm.Like the UroLift, Rezūm is valued by some men for its lack of sexual side effects. The physician numbs the penis and prostate and then inserts a needle into the prostate through which steam is released. In a typical Rezūm procedure, the doctor will perform between two and seven injections, each lasting nine seconds. Although minimally invasive, recovery from a Rezūm procedure can take months.
